{"paper_id":"68972872-110a-4d56-931b-6c69e3fbbe06","body_text":"~ 60 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2024; 8(4): 60-63 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2024; 8(4): 60-63 \nReceived: 15-06-2024 \nAccepted: 18-07-2024 \n \nHanaa Fathy El-Baiomy \nDepartment of Obstetrics and \nGynecology, Damanhour Medical \nNational Institute, Ministry of \nHealth, Damanhour, Egypt \n \nNareman Mahmoud Elhamamy \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nAhmed Mohamed Othman \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \nEsmat Hamdy Abozeid \nDepartment of Obstetrics and \nGynecology, Faculty of Medicine, \nTanta University, Tanta, Egypt \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nHanaa Fathy El-Baiomy \nDepartment of Obstetrics and \nGynecology, Damanhour Medical \nNational Institute, Ministry of \nHealth, Damanhour, Egypt \n \nEvaluation of ovarian reserve after different surgical \ntechniques in management of endometrioma \n \nHanaa Fathy El -Baiomy, Nareman Mahmoud Elha mamy, Ahmed \nMohamed Othman and Esmat Hamdy Abozeid \n \nDOI: https://doi.org/10.33545/gynae.2024.v8.i4a.1477 \n \nAbstract \nBackground: Endometriosis could be present among women without any symptoms, accounting for as \nmany as fifty percent of women seeking infertility treatment . Antral follicle count (AFC) as well as serum \nanti-Mullerian hormone (AMH) levels are often utilized as accurate quantitative ovarian reserve indicators. \nThis work was aimed at assessing different endometrioma surgical treatment modalities’ impact on ovarian \nreserve. \nMethods: Our prospective comparative study involved 40 cases whose ages fall between 20 and 35 years, \nfemale patients who are married, nullipara with unilateral endometrioma > 4 cm. Subject underwent a \nrandom equal allocation into two equal groups according to  patient's condition intra -operative, hence \ndecision of the operator: Group A (n=20): treated by laparoscopic excision of endometrioma and Group B \n(n=20): treated laparoscopically by evacuation of the cyst then by cyst wall’s cauterization utilizing Bipolar \nDiathermy. \nResults: A significantly variance among AMH levels was documented within group A as well as between \nAFC in group A and B and AMH in group B during various follow -up periods ( p<0.05). AMH within \ngroup A during various follow -up periods was significantly different between base line and after 6 months \n(P2 < 0.05). There was a significantly difference between base line with after 6 months, between base line \nwith after 3 months and between 3 months with 6 months (P1, P2, P3 < 0.05) regarding of AFC  within \ngroup A as well as AMH within group B during various follow -up periods. Pregnancy rate exhibited \nsignificant variances among both groups (p<0.05). \nConclusions: Both techniques, complete laparoscopic cystectomy and partial cystectomy with bipolar \ncoagulation of the cyst wall have adverse effect as regards ovarian reserve determined with serum AMH \nlevel. However, AFC increased after both techniques. No significant variance was documented among both \ngroups as regards the ovarian reserve’s degree of reduction. \n \nKeywords: Ovarian reserve, laparoscopic excision, endometrioma, antral follicle count, anti -mullerian \nhormone \n \nIntroduction  \nEndometriosis represents a chronic inflammatory condition linked to persistent pelvic pain, \naffecting six to ten percent of females within their reproductive age. The endometriosis \ndiagnosis remains definitive only while confirming endometrial like tissue lesions outside the \nuterus following the surgical procedure. Endometriosis could be present among  women without \nany symptoms, accounting for  as many as fifty percent  of women seeking infertility treatment. \nThe predominant endometriosis symptoms involve discomfort, gastrointestinal as well as urinary \nissues, along with exhaustion and sadness resulting from the persistent pain . There could be a \ndelay while diagnosis such a condition  since symptoms, involving  pelvic discomfort and/or \ninfertility, may or may not be oberverd among  all individuals. Additionally, they could also \nbe linked to other medical disorders [1]. \nThe current therapies for this condition involve  the surgical  lesions' excision  along with \nadministering medicines, inhibiting the ovarian hormones synthesis. More than fifty percent  of \nindividuals going through  surgery will need an additional surgical operation withi n five  years. \nAdditionally, several medical therapies have adverse side effects. Surveys conducted on \ncases regularly emphasize the symptoms alleviation  along with  enhancing medical treatments \nthat do not have any negative impact on fertility [2].  \nOvarian reserve refers to the reproductive capacity determined by the quantity and quality of \nresting primordial follicles that have the ability to mature into primary, antral, as well  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 61 ~ \nas ovulatory follicles. Antral follicle count (AFC) as well \nas serum anti -Mullerian hormone (AMH) levels are often \nutilized as accurate quantitative ovarian reserve indicators. \nPublications in the literature present comparative analysis \nstudies between different surgical techniques used in the \ntreatment of endometrioma [3].  \nAMH exhibits a  crucial role as regards the physiology  \nof ovaries. It is produced by the granulosa cells of developing \nfollicles, starting from the early stages of follicle growth until \ncyclic selection. AMH has a detrimental effect on the \nrecruitment of primor dial follicles [4]. The AMH level is a \ndependable and valuable indicator of ovarian reserve, since it \nconsistently decreases as a person ages and becomes \nundetectable during the perimenopause stage. It is widely agreed \nthat cases developing  endometrioma ha ve a more rapid fall in \nserum AMH levels as opposed  to healthy women. \nEndometrioma may mechanically  impact ovarian reserve \nvia compressing the adjacent ovarian cortex, which hinders \nvascular circulation, resulting in follicles loss [5]. \nEndometriotic cyste ctomies lead to a significant decrease in \nserum AMH levels, but do not affect the AFC. The negative \nimpact on AMH levels could  be reliably seen at several time \npoints, involving  early, intermediate, as well as late \npostoperative periods. Among women having endometrioma, the \nAMH level could be a more precise marker, assessing the risk \nfor the ovarian reserve’s iatrogenic depletion [6]. \nThis work was aimed at assessing different endometrioma \nsurgical treatment modalities’ impact on ovarian reserve. \n \nPatients and Methods \nOur prospective comparative study involved 40 cases whose \nages fall between 20 and 35 years, female patients who are \nmarried, nullipara with unilateral endometrioma > 4 cm. The \nresearch commenced following the Ethical Committee’s \napproval at Ta nta University Hospitals, Tanta, Egypt. All \nsubjects were allowed to sign an informed consent. \nWe excluded polycystic ovarian syndrome based on the \nRotterdam criteria, prior ovarian surgical procedures, any \novarian mass either benign or malignant, known en docrinal \ndisorders or other chronic conditions along with consuming oral \ncontraceptives or gonadotropin releasing hormone (GnRH) \nagonist or antagonist or any other medicines affecting ovarian \nfunction within a minimum of three months prior to the research. \nSubject underwent a random equal allocation into two equal \ngroups according to patient's condition intra -operative, hence \ndecision of the operator: Group A (n=20): treated by \nlaparoscopic excision of endometrioma and Group B (n=20): \ntreated laparoscopical ly by evacuation of the cyst then by cyst \nwall’s cauterization utilizing Bipolar Diathermy. \nAll subjects underwent a comprehensive medical history taking, \ngeneral assessment and ovarian reserve evaluation prior to \nsurgical procedure and at three, six month s postoperatively by: \n[serum AMH and AFC by transvaginal ultrasonography \n(TV/US). \n \nEvaluation of ovarian reserve prior to the surgical \nprocedure, at three, and six months postoperatively by \nSerum Anti- Mullerian Hormone (AMH)  \nDuring the time frame of 8 t o 9 AM, blood samples were \nobtained via  venipuncture then underwent storage  within tubes \ncontaining heparin. They  were then placed on ice till \nbeing centrifuged. The plasma obtained following centrifugation \n(With a force of 1200 times the acceleration due to gravity for a \nduration of 10 minutes) was separated into smaller portions and \nkept at a temperature of -20 °C until it was examined for AMH \nlevels. The plasma concentrations of AMH  were measured \nutilizing a commercially available ELISA  kit (MOFA Global \nAMH ELISA, Verona, WI) based on the instructions provided \nby the manufacturer. This analysis was  specifically to quantify \nAMH levels within serum  and plasma samples. The absorbance \nat 450 and 630 nm was measured employing a microplate \nspectrophotometer (BioTek Powerwave HT, Winooski, VT). \n \nAntral Follicular Count (AFC) by TV/US \nTransvaginal sonography was employed  on cycle day 1, 2, 3, or \n4 to examine the ovaries. The same observer conducted  \nsonography measures, G.S., utilizing  a 7.5 MHz transvaginal \nprobe on a Toshiba Capasee SSA -220A. The ovary's \nexamination was conducted via  scanning from the outside to \ninner edge.  Every follicle with a size falling between two and \nten mm was measured then counted within  both ovaries. The \ntotal of both numbers equated to  the AFC. The follicle size was \ndetermined by taking two or three perpendicular  measures, \naccording to  the follicle's diameter  (6 mm). Each  follicle's \nvolume was determined utilizing  the equation for the volume of \nan ellipsoid, which is L3W3D3p/6. The tota l follicular volume \nwas calculated via  summing the all follicles volumes  measuring \nup to 10 mm in size within both ovaries. The mean follicular \nvolume was determined through  dividing the total follicular \nvolume by the  follicles' number  counted. Ovarian vol ume was \ndetermined via measuring the ovarian contour's diameter in three \nperpendicular directions, employing  the formula for the volume \nof an ellipsoid (D13D23D33p/6). The total ovarian volume was \ncalculated through  adding together the left as well as  right \novary's volumes. Prior research  have shown intra - as well as \ninter-observer variability while  evaluatng AFC as well \nas ovarian volume. \nThe primary outcome was assessed by measurement of serum \nAMH and AFC by TV/US before surgery and after surgery by 3 \nm and 6 m and secondary outcome: was assessed by occurrence \nof pregnancy. \n \nStatistical analysis  \nData underwent a statistical analysis utilizing SPSS v26 (IBM \nInc., Chicago, IL, USA). Quantitative variables were exhibited \nas mean and SD then a comparison amon g both groups was \nemployed with unpaired Student's t - test. Qualitative variables \nwere exhibited as frequency and percentage (%) then underwent \nanalysis with the Chi -square test or Fisher's exact test when \nappropriate. A two tailed P value of below 0.05 de emed to \nexhibit a statistically significance.  \n \nResults  \nThere was insignificantly variance among both groups as regards \ndemographic data as well as size of endometrioma (p>0.05). \n \nTable 1: Comparison among both groups as regards demographic data \nas well as size of endometrioma \n \n Group A (n=20) Group B (n=20) P \nAge (Years) 26.3±4.52 28±5.29 0.141 \nBMI (kg/m2) 26.235±3.51 26.435±3.65 0.430 \nSize of endometrioma 5.02±0.62 4.925±0.59 0.311 \nData are exhibited as mean ± SD. BMI: Body mass index.  \n \nA significa ntly variance between levels of AMH was \ndocumented within group A within various follow -up periods \n(p<0.05). There was a significantly difference between base line \nand after 6 months (P2 < 0.05) while there was insignificant \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 62 ~ \ndifference between base line w ith after 3 months and between 3 \nmonths with 6 months (P1, P3 > 0.05) regarding levels of AMH \nin group A within various follow -up periods. There was a \nsignificantly different between AFC within group A as well as B \nand AMH within group B during various fol low-up periods \n(p<0.05). There was a significantly different between base line \nwith after 6 months, between base line with after 3 months and \nbetween 3 months with 6 months (P1, P2, P3 < 0.05) regarding \nof AFC within group A as well as AMH within group B during \ndifferent periods of follow up. Table 2 \n \nTable 2: Comparison between levels of AMH and AFC in group A and \nB within various follow-up periods \n \n At base line After 3 months After 6 months P \nGroup A \nAMH 3.5±1.2 3±1 2.5±0.8 0.005* P1=0.069, P2=0.002*, P3=0.061 \nAFC 4.8±0.7 7.1±1.1 10.5±1.4 0.001* P1=0.006*, P2=0.001*, P3=0.042* \nGroup B \nAMH 3.79±1.32 3.28±1.13 2.85±1.01 0.036* P1=0.089, P2=0.002*, P3=0.061 \nAFC 4.68±0.62 6.83±1.18, 9.38±2.14 0.001* P1=0.021*, P2=0.001*, P3=0.003* \nData are  exhibited as mean ± SD. *significant p value < 0.05, P1 \ncomparison among base line as well as following three months, P2 \ncomparison among base line and following six months, P3 comparison \namong three as well as six months, AMH: Anti -Mullerian hormone, \nAFC: Antral follicle count.  \n \nThere was insignificant variance among both groups as regards \nAMH within various follow -up periods ( p>0.05) and AFC at \nbase line and after 3 months ( p>0.05) while a significantly \nvariance was documented after six months (p<0.5). Table 3 \n \nTable 3: Comparison among both groups regarding AMH and AFC \nwithin various follow-up periods \n \n Group A (n=20) Group B (n=20) P \nAMH \nAt base line 3.5±1.2 3.79±1.32 0.328 \nAfter 3 months 3.0±1.0 3.28±1.13 0.310 \nAfter 6 months 2.5±0.8 2.85±1.01 0.098 \nAFC \nAt base line 4.8±0.7 4.68±0.62 0.328 \nAfter 3 months 7.1±1.1 6.83±1.18 0.209 \nAfter 6 months 10.5±1.4 9.38±2.14 0.046* \nData are exhibited as mean ± SD. *significant p value < 0.05, AMH: \nAnti-Mullerian hormone, AFC: Antral follicle count. \n \nPatients who had pregnancy rate in group A were 14(70%) and \nin group B were 7(35%) while patients who had not pregnancy \nrate were 6(30%) and 13(65%) in both groups respectively. \nThere was a significantly variance among both groups as regards \npregnancy rate (p<0.05). Table 4 \n \nTable 4: Comparison among both groups as regards pregnancy rate \n \n  Group A (n=20) Group B (n=20) P \nPregnancy rate No 6(30.0%) 13(650%) 0.026* Yes 14(70.0%) 7(35.0%) \nData are exhibited as frequency (%). *Significant p value < 0.05.  \n \nDiscussion \nEndometriosis is through to be a factor in infertility due to \nincreased the disease incidence among sub -fertile women \n(Reaching fifty percent) as opposed to other women having a \nhistory of proven fertility (Five to ten percent) [7]. \nRecently, a marked rise as regards the infertile patients’ number \ndeveloping endometriosis have been documented. It is uncertain \nif this indicates a rise in numbers or just signifies the higher \nfrequency of laparoscopy use. The dysmenorrhea prevalence \namong women is e stimated to fall between forty and sixty \npercent, whereas the subfertility prevalence is estimated to fall \nbetween twenty and thirty percent among women [8].  \nEndoscopic surgery adheres to the essential microsurgical \nprinciples of delicate tissue manipulat ion, continuous irrigation, \ncautious bleeding control, as well as  accurate tissue dissection. \nThe choice of operative procedures for endometriosis depends \non the lesions type as well as extent. Several technologies could \nbe utilized, with hydrodissection a s well as  CO2 laser being the \nmost effective methods [9].  \nIn our study the results showed that the hormonal assay in this \nstudy showed no significant variance among both groups as \nregards AMH. In group A and B, a significant decrease within \nAMH level was documented following 6 as opposed to base line \nlevel.  \nOur findings supported a meta -analysis by Raffi et al . [10] \nsuggesting a negative effect linked to endometriomas’ excision \non ovarian reserve, involving a marked decline as regards \ncirculating AMH post operatively, which could occur as a result \nof comparable mean age group as well as sample size. \nBiacchiardi et al . [11] documented no significant variance \nbetween AMH level among both laparoscopic excision group as \nwell as bipolar diathermy.  \nIn the result s of our study the AFC shows insignificant \ndifference among both groups at base line and following three \nmonths, while after six months the AFC was significantly \ngreater within group A as opposed to group B.  Within group A \nand B, a significant rise as rega rds AFC was documented after \nthree months and following 6 months compared to base line \nvalue. Celik et al. [12] addressed significant drop of serum AMH \nat the sixth month (61%) post operatively after laparoscopic \nendometrioma stripping. The AMH level exhib ited a significant \nreduction among cases having the cyst below 5 cm as well as \namong those having bilateral endometrioma. Raffi et al . [10] \nreported a statistically significant decline (thirty percent) as \nregards serum AMH post operatively in patients with  unilateral \nendometrioma. This indicates a significant ovarian reserve \ndamage following ovarian cystectomy for endometrioma.  \nThe ovarian endometrioma’s laparoscopic treatment has been \nlinked to worsening ovarian reserve in several different ways. \nThese in clude surgical -related local inflammation, heat injury \nfrom adhering cyst wall or bleeding arteries, and unintentional \nhealthy ovarian cortex removal [13].  \nOur research addressed that pregnancy rate in group A were 14 \n(70%) and in group B were 7 (35%). A statistically significant \nrise as regards pregnancy rate was documented among  patients \ntreated by laparoscopic excision of endometrioma more than the \npatients treated laparoscopically by evacuation of the cyst then \nby cauterization of the cyst wall by Bipo lar Diathermy. \nSupporting our research, Pais et al . [14] investigated the \npregnancy chances following endometriomas’ laparoscopic \nexcision fell between 30% and 67%, addressing an overall \nweighted mean around fifty oercent. Zhou et al. [15] performed a \nprospective study involving 124 cases aligned with such \nfindings, addressing a total spontaneous pregnancy rate reaching \n50.49% at twenty -four months following excisional surgical \nprocedure.  \nThe procedure utilized  for hemostasis following  cysts' \nexcision is one of the factors, probably inducing harm to  ovarian \nreserve. Common methods for achieving hemostasis involve \nutilizing sutures, haemostatic gel, or bipolar cauterization (BC). \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 63 ~ \nThe drawbacks of suturing involve the need for specialized skills \nas well as ischemia possibilities induced by elevated intraovarian \npressure during suture tightening. Hemostatic gels are costly \nalong with potentially causing  severe complications such as \nbowel obstruction or thrombosis. BC, or cryotherapy, \nrepresents a cost -effective, uncomplicated, as well as  efficient \nmethod. However, caution must be implemented \nfor minimizing thermal damage risks [16].  \nLimitations involve a single -senter study with a relatively \nmodest sample size. Therefore, more research should be \nimplemented for  calrifying issues associated with ovarian \nreserve with the ovarian endometrioma’s conservative treatment, \nspecifically in terms of medical or expectant care. Research on \nthe effect of surgery for endometrioma on ovarian reserve \nshould continue to be prior itized in the field of reproductive \nmedicine. \n \nConclusions \nBoth techniques, complete laparoscopic cystectomy and partial \ncystectomy with bipolar coagulation of the cyst wall have \nadverse effect as regards ovarian reserve determined with serum \nAMH level. Ho wever, AFC increased after both techniques. No \nsignificant variance was documented among both groups as \nregards the ovarian reserve’s degree of reduction. \n \nFinancial support and sponsorship: Nil \n \nConflict of Interest: Nil \n \nReferences \n1. Saunders PTK, Horne AW . Endometriosis: Etiology, \npathobiology, and therapeutic prospects. Cell. \n2021;184:2807-2824. \n2. 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Mısırlıoğlu S, Türkgeldi E, Yağmur H, Urman B, Ata B. \nUse of a gelatin -thrombin hemostatic matrix in obstetrics \nand gynecological surgery. Turk J Obstet Gynecol. \n2018;15:193-199. \n \nHow to Cite This Article \nEl-Baiomy HF, Elhamamy NM, Othman AM, Abozeid EH. Evaluation of \novarian reserve after different surgical techniques in management of \nendometrioma. International Journal of Clinical Obstetrics and \nGynaecology. 2024;8(4):60-63.  \n \n \nCreative Commons (CC) License \nThis is an open access journal, and arti cles are distributed under the terms \nof the Creative Commons Attribution -NonCommercial-ShareAlike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}